Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ahva Care Of Winfield during CMS and state inspections, most recent first.
Two residents with psychiatric and medical conditions engaged in a physical altercation after a verbal dispute, resulting in both individuals hitting each other before staff intervened. The incident was witnessed by staff, documented in the EMR, and reported to the abuse coordinator. Both residents were cognitively intact and had a history of behavioral issues, but the facility failed to prevent the physical abuse as required by policy.
The facility failed to maintain a clean and comfortable environment for residents, as observed in four cases. Residents reported cold room temperatures, with one room confirmed at 63°F, below the policy range. A broken thermostat was identified as a cause. Additionally, a resident's room was found unclean, with a dirty urinal on the meal tray. These issues indicate non-compliance with the facility's policy on maintaining a homelike environment.
The facility failed to manage controlled medications properly and ensure the availability of as-needed medications. Controlled substances were improperly stored and not disposed of as required, and a resident's hemorrhoid cream was unavailable despite being ordered. The facility's policies on medication management were not followed.
A facility failed to ensure a resident's call light was within reach, leading to a deficiency in accommodating resident needs. The resident, who requires substantial assistance and is at risk for falls, reported that staff often leave the call button out of reach, resulting in a previous fall. The DON confirmed that staff should ensure call lights are accessible.
A facility failed to maintain accurate advanced directives for three residents, as discrepancies were found between their POLST forms and EMRs. Two residents had DNR orders on their POLST forms but were listed as full code in their EMRs, while another resident's EMR lacked a code status order. The Social Worker confirmed the DNR wishes, but the facility's policy requiring prominent display of advance directives in medical records was not followed.
A hospice resident experienced an unwitnessed fall and was transferred to the hospital without timely notification to the POA, physician, and hospice provider. The resident, who had an order not to be hospitalized, was admitted to the hospital for dehydration and abnormal sodium levels. The facility's policy requires immediate notification of significant changes, which was not followed, leading to the resident's hospitalization against the care plan.
A facility failed to follow a hospice physician's order for a resident who was not to be hospitalized. Despite the order, the resident was sent to the hospital after an unwitnessed fall. The RN involved was unaware of the order, and the hospice nurse was informed only after the hospitalization. The facility's policy mandates adherence to physician orders and notifying the provider upon a change in condition.
The facility failed to safely transfer three residents using mechanical lifts, resulting in unsafe practices. Residents with conditions like muscle weakness and hemiplegia were transferred with slings that were too loose and without necessary knee belt attachments. Staff were unsure about the appropriate use and sizing of equipment, leading to compromised resident safety.
A resident's extended-release antihypertensive medication, Diltiazem ER, was improperly administered by a nurse who crushed the tablet before giving it to the resident. This action was against the medication's administration instructions and the facility's policy, leading to a significant medication error.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, as evidenced by an altercation between two residents. On June 7, 2025, two residents with multiple psychiatric and medical diagnoses engaged in a physical confrontation near the facility's elevator. Both residents exchanged words, which escalated into physical contact, including hitting and kicking. Staff intervened and separated the residents, but both admitted to hitting each other during the incident. Documentation in the electronic medical records and behavior monitoring indicated that both residents were observed to be physically aggressive and expressed frustration or anger towards others on the day of the incident. Staff members, including a CNA, confirmed witnessing the altercation and intervening to stop it. The incident was reported to the abuse coordinator, and body checks were performed, revealing no visible injuries or complaints of pain from either resident. Both residents were cognitively intact but had histories of psychiatric disorders, including schizoaffective disorder, bipolar disorder, and psychosis. The altercation was reportedly triggered by a dispute over bathroom use. The facility's policy requires the prevention of abuse and the provision of a safe environment, but the incident demonstrated a failure to prevent resident-to-resident physical abuse as required.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for its residents, as evidenced by the observations and interviews conducted. Four residents were affected by this deficiency. One resident, who was cognitively intact, reported that her room was always cold, and she was observed covered with two comforters. Another resident also complained about the cold temperature in her room and was seen covered with a comforter. A third resident was observed wearing winter attire indoors due to the cold room temperature, which was confirmed to be 63°F, below the facility's policy range of 71 to 81°F. The Maintenance Director acknowledged the issue, noting that the thermostat in the resident's room was broken. Additionally, another resident was found in an unclean environment, with a foul odor emanating from his side of the room. His urinal, which was placed on his meal tray, had a dark brown substance around the rim, and the resident stated it had been dirty for a long time. This resident was also cognitively intact. The facility's policy on maintaining a homelike environment, which includes comfortable room temperatures and cleanliness, was not adhered to, leading to these deficiencies.
Deficiencies in Medication Management and Availability
Penalty
Summary
The facility failed to properly manage and dispose of controlled medications and ensure the availability of as-needed medications for residents. During an inspection, it was observed that a resident's Ativan tablets were improperly stored in a refrigerator and not logged in the narcotic control binder, despite being discontinued. Another resident's Lorazepam punch card had a pill slot taped over with a pill inside, indicating improper handling. Additionally, controlled medications for two discharged residents were not removed and disposed of as required, with their records not maintained in the narcotic control binder. The facility's policy mandates that discontinued controlled substances be destroyed in a controlled manner, which was not adhered to in these cases. Furthermore, a resident requested hemorrhoid cream, which was not available for administration despite being ordered by a physician. The LPN acknowledged the absence of the over-the-counter medication and had informed a supervisor days prior, but the issue was not resolved. The Director of Nursing confirmed that the medication was not covered by the resident's insurance but emphasized that medications should be available for residents. The facility's policy requires that all medications, including over-the-counter ones, be obtained and available for residents, which was not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call light within reach for a resident, identified as R130, which is a deficiency in accommodating the needs of residents. On February 18, 2025, R130 was observed sitting on the side of his bed with his call button draped over the side of his wheelchair, out of reach. R130 expressed concern about the difficulty in accessing the call button without risking a fall. He reported that staff often do not provide him with the call button, estimating this occurs 75% of the time. R130 also mentioned a previous fall that occurred when he attempted to reach for the call button. His Minimum Data Set (MDS) indicated intact cognition and a need for substantial assistance with personal hygiene, while his care plan highlighted a risk for falls and included interventions such as keeping the call light within reach. The Director of Nursing confirmed that staff should ensure the call light is accessible to residents when leaving the room.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to maintain accurate advanced directives in the residents' medical records, affecting three residents. A Licensed Practical Nurse (LPN) discovered discrepancies between the residents' POLST forms and their Electronic Medical Records (EMRs). Specifically, two residents had POLST forms indicating Do Not Resuscitate (DNR) orders, but their EMRs showed full code orders, which means they were to be resuscitated. Another resident's EMR did not have any code status order, despite having a POLST form indicating DNR. The LPN confirmed that the information in the DNR binder, which contained the POLST forms, should match the residents' EMRs to ensure staff respond appropriately during medical emergencies. The Social Worker, responsible for assisting residents with their POLST forms, confirmed the accuracy of the DNR wishes on the POLST forms for the three residents. However, the facility's policy on advance directives, which requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record, was not followed. The care plans for the residents included interventions to document the DNR status on the Physician's Order Sheet and inform caregivers, but these were not accurately reflected in the EMRs, leading to the deficiency.
Failure to Notify POA and Hospice Before Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA), physician, and hospice provider in a timely manner before transferring a hospice resident, identified as R131, to the hospital following a fall incident. R131, who was admitted to hospice care for comfort care due to cerebral vascular disease and other diagnoses, experienced an unwitnessed fall. The nursing progress notes indicated that the fall occurred at 12:25 PM, and the resident was transferred to the hospital for dehydration and abnormal sodium levels. However, the POA was not informed until around 7:08 PM, after the resident had already been admitted to the hospital, contrary to the facility's policy which requires immediate notification of significant changes in condition. The report highlights that the hospice provider was informed of the resident's condition change at 2:45 PM, after the resident had already been sent to the hospital. The hospice nurse stated that the facility should have notified them immediately after the fall, as there was an existing order from the hospice physician not to hospitalize the resident. The Director of Nursing confirmed that the facility's practice is to notify the appropriate parties as soon as any change in resident conditions or hospital transfer occurs. This deficiency in communication and adherence to policy resulted in the resident being hospitalized against the hospice care plan and without the POA's prior knowledge.
Failure to Follow Hospice Physician's Order
Penalty
Summary
The facility failed to adhere to the hospice physician's order for a resident who was not to be hospitalized. The resident, who was under hospice care for comfort care only due to cerebral vascular disease and other medical conditions, experienced an unwitnessed fall. Despite the hospice order indicating 'do not hospitalize,' the facility called 911 and transferred the resident to the hospital. The registered nurse involved stated she was unaware of the order not to hospitalize the resident. The Director of Nursing confirmed that nurses are expected to follow physician orders. The resident's electronic medical records indicated severe cognitive impairment and dependency on staff for daily activities. The hospice nurse was informed of the hospitalization only after the resident had been sent to the hospital. The facility's policy requires physician orders to be followed and the resident's provider to be notified for further medical intervention upon a change in condition.
Unsafe Transfer Practices with Mechanical Lifts
Penalty
Summary
The facility failed to safely transfer residents who required the use of a mechanical lift, affecting three residents. The first resident, R104, had multiple diagnoses including lack of coordination and muscle weakness, requiring a mechanical sit-to-stand lift for transfers. During an observed transfer, the staff used a sling that was not securely fastened, and the knee belt attachment was missing, leading to an unsafe transfer where the resident was not properly supported. The second resident, R32, also required a mechanical lift for transfers due to conditions like muscle weakness and unsteadiness. During her transfer, the staff used a sling that was too large and not securely fastened, despite having access to different sizes. The staff attempted to use a smaller sling but still proceeded with the transfer using an ill-fitting sling, compromising the resident's safety. The third resident, R75, had conditions including hemiplegia and muscle weakness, necessitating the use of a mechanical lift. The staff used a rental machine without a knee belt and a sling that was too loose, failing to provide adequate support. The facility's Director of Nursing and Risk Manager Consultant were unsure about the necessity of knee belts and the appropriate sizing of slings, leading to inconsistent and unsafe transfer practices.
Improper Administration of Extended-Release Antihypertensive Medication
Penalty
Summary
The facility failed to safely administer an extended-release antihypertensive medication to a resident, identified as R92, during a medication administration process. On the morning of February 19, 2025, a registered nurse, V16, crushed and mixed R92's Diltiazem ER 120 mg tablet with applesauce before administering it orally. This action was contrary to the medication's administration instructions, which specified that the tablet should be swallowed whole and not chewed or crushed. The pharmacist, V14, confirmed that crushing the tablet would cause it to lose its extended-release properties, leading to quicker absorption of the dosage. The facility had a policy in place for administering medications safely and timely, as well as a list of medications that should not be crushed, which included Diltiazem. Despite these guidelines, the nurse's action of crushing the extended-release tablet was inconsistent with the manufacturer's instructions and the facility's policy. The resident's order summary report allowed for medications to be crushed if indicated by the manufacturer's guidelines, which was not the case for Diltiazem ER. This incident highlights a significant medication error in the administration process for the resident with hypertensive heart disease.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Winfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wynscape Health & Rehab | 0.6 mi | ★★★★★ | 3 | 0 |
| Dupage Care Center | 0.7 mi | ★★★★★ | 13 | 0 |
| Wheaton Village Nrsg & Rhb Ctr | 1.3 mi | ★★★★★ | 2 | 0 |
| Covenant Living - Windsor Park | 2.5 mi | ★★★★★ | 0 | 0 |
| West Chicago Living And Rehab Center | 2.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.